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Story Publication logo May 3, 2021

The Global Gag Rule’s Long Shadow in Pakistan

A woman is walking toward the left of the frame. She's wearing clear plastic gloves, a hospital mask pulled down around her chin, a light pink scarf covering her head and draped around her body. Behind her, another woman stands in the doorway of a stone building.

In January, President Joe Biden repealed the Mexico City Policy, or global gag rule, which bars non...

A health worker from a women's clinic in Islamabad.
Safina Bibi, a health worker from a women’s health clinic supported by Greenstar Social Marketing, visits the houses of her patients in a settlement for Afghan refugees in the suburbs of Islamabad on April 1. Image by Betsy Joles. Pakistan, 2021.

PUNJAB and SINDH PROVINCES, Pakistan—On a Saturday in February, four women came to a reproductive health clinic in Rawalpindi, Pakistan, seeking to end their pregnancies. Three of the four were married mothers who already had multiple children like many women receiving abortion care in Pakistan. When Naseem Tariq, a doctor at the clinic, lifted one client’s shirt to take an ultrasound, the stretch marks from her last baby were still visible.

Tariq sees patients with unintended pregnancies almost every day. After each consultation, she tells women about their family planning options. Most patients don’t have access to any long-term birth control method, often because husbands or mothers-in-law don’t allow it or because they can’t easily afford it. Just 34 percent of married Pakistani women use contraception and only 25 percent rely on modern methods, based on the latest state-supported survey. “They are poor. They have seven to eight kids. The access to family planning services is not there,” Tariq said. “What comes out of this? Unwanted pregnancies.”

Despite abortion only being legal in Pakistan under certain conditions, the country has one of the highest abortion rates in the world—an estimated 50 abortions per 1,000 women, according to 2012 research by the Population Council, one of the most comprehensive reports on the topic. This makes health organizations in Pakistan particularly vulnerable to funding restrictions that target abortion. Family planning initiatives in Pakistan suffered under the Trump administration, which reinstated and expanded the Mexico City policy to ban recipients of U.S. assistance for global health from providing abortions, counseling women about abortions, or giving referrals for abortion services—even with their own private funds.

U.S. President Joe Biden repealed the so-called global gag rule shortly after taking office in January, ending restrictions on an estimated $12 billion of U.S. foreign assistance. Although the change reopens channels for funding, limitations around abortion remain a defining characteristic of the U.S. model for family planning, affecting the care that reproductive health organizations can provide. With the remaining restrictions on funding and the lingering effects of the global gag rule, organizations on the ground in Pakistan still face obstacles to family planning and safe abortion care.

A nurse attends to a mother and her new baby at a hospital in Lahore.
A nurse attends to a mother and her new baby at the Services Institute of Medical Sciences, a public hospital in Lahore, Pakistan, on April 2. Image by Betsy Joles. Pakistan, 2021.

A delivery room is shown at Anila Maternity Center in northwest Karachi on March 9. The clinic, which was previously supported by the U.S. Agency for International Development, lost its supply of birth control when U.S. funding was pulled prior to the global gag rule, leaving women in the community with few other options for family planning. Image by Betsy Joles. Pakistan, 2021.

The success of family planning in Pakistan is crucial as its population balloons, putting pressure on infrastructure and resources. Despite a push by the Pakistani government to increase the prevalence of contraception, many women still lack access. Birth control use and fertility rates have actually declined slightly, according to the 2013 and 2018 Pakistan Demographic and Health Surveys, which reproductive health advocates say suggest more women are seeking abortions.

Abortion is legal in Pakistan to save a woman’s life or to provide “necessary treatment” early in pregnancy, but some doctors won’t perform the procedure due to personal values, societal pressure, or misinterpretation of the law. Many women seek services from untrained providers or use traditional methods to end their pregnancies instead, resulting in complications for 68 percent of poor rural women. The private sector, including nongovernmental organizations, fills the gap for most safe abortion services as well as counseling and legal clarification trainings for doctors. Given the prevalence of complications and the stigma around abortion, reproductive health providers in Pakistan are especially focused on post-abortion care.

Family planning organizations tend to rely on foreign donors, and those supported by U.S. funding are exposed to the same conservative pressures faced by domestic organizations in the United States. The U.S. government has played a significant role in Pakistan’s family planning program since its inception in 1965, at times providing as much as 40 percent of the program’s supplies, including contraception. Just over 3 percent of Pakistan’s GDP in 2018 was allocated to health care, and provincial budgets for population welfare are limited.

A poster about birth control in a women's health center in Islamabad.
A poster about birth control hangs on a wall in a women’s health center for Afghan refugees in the suburbs of Islamabad on April 1. Image by Betsy Joles. Pakistan, 2021.

When the Trump administration reinstated the global gag rule, it put organizations providing these services in a bind as recipients and subrecipients of U.S. aid, forcing some of them to shut down clinics. “We were not willing to sign this certification, and our funding was closed right away,” said Syed Kamal Shah, CEO of Rahnuma-Family Planning Association of Pakistan, one of the country’s population welfare pioneers.

But even with Biden’s repeal of the policy, organizations face other funding restrictions on U.S. assistance. The Helms Amendment, enacted in 1973 as part of a backlash to Roe v. Wade, still forbids U.S. foreign aid from going toward “abortion as a method of family planning” or to entities that “motivate or coerce any person to practice abortion.” The policy intends to prevent U.S. taxpayer money from being used to perform abortions overseas, but in practice, it also stops organizations from providing related services, including counseling and—crucially in Pakistan—post-abortion care.

Although the Helms Amendment technically makes an exception for post-abortion care, it limits funding for the tools used to provide it, which are the same as those used for abortions. According to Asma Balal, the country director for the Marie Stopes Society Pakistan, in the past, the organization couldn’t use U.S. Agency for International Development (USAID) money to procure misoprostol or manual vacuum aspiration kits for treating women seeking treatment for botched abortions. “Post-abortion care is a lifesaving service. But we were not even allowed to provide that,” Balal said.

Men stand at a container clinic that provides women health services in a village outside Sargodha, Pakistan.
Men stand at a container clinic that provides women health services in a village outside of Sargodha, Pakistan, on March 17. Image by Betsy Joles. Pakistan, 2021.
A boy rides a motorcycle through an empty dirt log near a midwife's clinic in Karachi.
A boy rides a motorcycle through an empty dirt lot near a midwife’s clinic in western Karachi, Pakistan, on March 10. Family planning services in Pakistan are often limited in remote areas, where women rely on clinics supported by humanitarian funds for free or low-cost birth control. Image by Betsy Joles. Pakistan, 2021.

U.S. support for Pakistan’s population program, as elsewhere, has fluctuated depending on the party that holds the White House since former U.S. President Ronald Reagan first introduced the global gag rule in 1984. Under pressure to mollify religious groups and right-wing lobbies, Republican administrations have consistently scaled back USAID activities related to population and family planning, only for Democratic administrations to ramp them up again. This seesaw effect can be jarring for aid recipients, Balal said. “When the project is pulled, it’s not just the project. Then your whole system is shaken,” she said.

Because of the limitations that come with U.S. assistance, some trepidation remains among reproductive health providers about seeking support from the United States. In Pakistan, where foreign funding is sometimes viewed with suspicion, the early termination of programs due to restrictions can undermine the credibility of organizations providing safe abortion services. “Suddenly, your clinic was closed. And then the people will say, ‘Yeah, but what was their agenda? There was something wrong with them,’” Shah said.

Women wait for gynecology outpatient department services at the Services Institute of Medical Sciences in Lahore, Pakistan, on April 2. Image by Betsy Joles. Pakistan, 2021.
A woman sites with her baby at a health center in Lahore.
A woman sits with her baby at the Services Institute of Medical Sciences in Lahore, Pakistan, on April 2. Image by Betsy Joles. Pakistan, 2021.

The ideological restraints of U.S. policies on abortion have lasting effects on family planning as a whole. U.S. funding restrictions have made it more difficult for reproductive health organizations to source birth control. A USAID project that put $160 million toward contraception in Pakistan ended in 2016, taking a major supply off the table for four years. “With the gag rule, any negotiation, any opportunity that would exist also went away,” said Sana Durvesh, the deputy general manager of programs at Greenstar Social Marketing, a social enterprise that provides reproductive health care products and services.

Under Biden, new procurements with U.S. funding will take time to get up to speed. Pakistan currently gets most of its contraceptives through international bidding, and critical shortages remain. Intrauterine devices are in particularly short supply due to soured trade relations between Pakistan and India, which affects imports.

The chilling effect of the conservative policies also disrupted partnerships among reproductive health organizations within Pakistan that will be slow to resume. Ghulam Shabbir Awan, the Pakistan director of Ipas, said he noticed organizations with U.S. ties had shied away from working together or stopped attending meetings about abortion services. “They categorically said if you want to include us in a partnership, it should not be abortion-related,” he said. Not being able to partner with others in the field presents another challenge to advocating for safe abortions, limiting the reach of services and trainings.

Above and below: Health workers Safina Bibi and Zubaria Mukhtar from a clinic supported by Greenstar Social Marketing visit women in a settlement for Afghan refugees in the suburbs of Islamabad on April 1.
Above and below: Health workers Safina Bibi and Zubaria Mukhtar, from a clinic supported by Greenstar Social Marketing, visit women in a settlement for Afghan refugees in the suburbs of Islamabad on April 1. Image by Betsy Joles. Pakistan, 2021.

Although the global gag rule is no longer in effect, the ideologies that underpin it remain—particularly in the Helms Amendment, which continues to stop billions of dollars from going toward abortion-related care. With a Democratic president, the tone on reproductive health has shifted, but the issue of abortion still polarizes Congress. The Global Health, Empowerment, and Rights Act—which would permanently repeal the global gag rule—and the more recent Abortion is Health Care Everywhere Act—which aims to repeal the Helms Amendment—will both face significant Republican opposition.

By comparison, although there is stigma around abortion in Pakistan, it remains mostly off the radar of the most conservative factions, in part because the law is vague enough to appease opponents while allowing some space for doctors who provide abortion services. “We are in a good place right now in the sense that abortion is not one of those right-wing agenda issues [in Pakistan]. It’s not a hotly contested debate the way it is in the U.S.,” said Sara Malkani, a lawyer and advisor for the Center for Reproductive Rights.

But as long as unsafe abortions continue to be a problem in Pakistan, policies that limit reproductive health care will only further endanger women. “If they are not provided safe services, certainly they will lose their life,” Awan said. “Abortions are not stopping in Pakistan.”

Health workers Safina Bibi and Zubaria Mukhtar from a clinic supported by Greenstar Social Marketing visit women in a settlement for Afghan refugees in the suburbs of Islamabad on April 1.
Image by Betsy Joles. Pakistan, 2021.

This story was made possible with support from the Pulitzer Center on Crisis Reporting.

Betsy Joles is a journalist in Pakistan. Twitter: @BetsyJoles


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